Assist in Planning for Appropriate Termination

As we continue our exploration of client retention and how this can decrease stress for clinicians by decreasing early termination of clients we will be looking at Chapter 5 - “Assist in Planning for Appropriate Termination” from the book, Premature Termination in Psychotherapy - Strategies for Engaging Clients and Improving Outcomes, written by Joshua K. Swift and Roger P. Greenberg.

"If I see an ending, I can work backward.” - Arthur Miller

Clients often begin treatment focused only on the present moment.  They can sometimes be so worried about what types of things will or should happen in therapy and whether their therapist will respect their values and opinions that they forget to look at the big picture.  However, once clients have developed clear and appropriate expectations through role induction and they know that their preferences will be considered, they will be ready, and willing, to start thinking about the end of psychotherapy and what it is that they are trying to achieve while in treatment.

Similarly, by talking about and planning for the end of therapy early on, clients are better able to commit to a full course of treatment and make the most of each and every session.  By having this type of discussion with their therapist at the beginning of therapy, they will have a goal to look forward to and will know what to anticipate in the end.

Talking with clients about appropriate termination includes:

1. providing them with education about typical treatment durations
2. developing a plan for recognizing and talking about desires to end therapy once progress had been made
3. discussing what to do if desires to end therapy prematurely do arise.

By having clients talk about the end of treatment, they are better able to anticipate all of the potential benefits that can come through engaging in therapy.  Additionally, by having a specific end goal in mind, clients may be more willing to push through the costs that may come up during treatment and thus be less likely to drop out prematurely.

Interesting Fact:

In one study it was found that 60% of clients expect to recover by eight sessions of treatment, however, the literature indicates that only between 10%-30% do recover in this short amount of time.

Clients can be informed about some of the reasons for having psychotherapy sessions extend over a period of several months and told that added benefits may flow from a treatment that is not overly abbreviated.  For instance, it can be noted that psychotherapy is often usefully extended when discussion reveals that there are more issues to be dealt with after the initial complaint is resolved.  Relatedly, over time, interactions with a therapist may lead to extending the goals of therapy.

Endings can often be just as intimidating as beginnings, particularly if the client does not know what to expect from the ending.  Even if clients feel like they are ready for treatment to end, they may be hesitant about bringing up this possibility with their therapist because they worry that their therapists might disapprove or that they might hurt their therapists’ feelings.  Rather than face these possibilities, some clients may simply choose to end therapy abruptly when they feel it is time.  Although such clients may have made significant progress and may actually be ready to end therapy, if they discontinue on their own, they miss the opportunity for gaining closure and experiencing the benefits that an appropriate termination can provide.

Given that 20% of clients do prematurely terminate from treatment, one might guess that an even greater percentage have some thoughts of dropping out at some point during therapy.  These thoughts could be due to building frustration with treatment or the therapist, or they may simply occur because the costs associated with continued attendance are starting to outweigh the perceived therapeutic benefits.  If they have not been warned that thoughts like this may occur, clients are more likely to act on them without ever discussing them with the therapist.  In contrast, if thoughts of this type are normalized and clients are instructed on what to do with them, they will be more likely to talk about them with their therapist.  Together the therapist and client can then work on a plan for making changes to treatment if needed or making a plan for collaboratively ending therapy.

Helping clients think about termination right from the start of treatment is another useful technique for reducing premature termination in practice.  When clients know approximately how long treatment will last, they may be more likely to push through some of the ups and downs associated with engaging in therapy and less likely to mistake early improvements for recovery.  Two additional benefits of discussing termination with clients early on is that they are then able to recognize that desires to unilaterally terminate are normal and they know it is ok to talk to their therapists about their desires to end treatment